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NURSING MANAGEMENT
NURSING PROCESS FOR MOTHER:
1. Nursing diagnosis : Anxiety related to outcome of pregnancy and health of unborn child as witnessed by mother’s frequent doubts about the pregnancy outcome
SUBJECTIVE DATA OBJECTIVE DATA
Mother verbalizes that her baby is very small and there is decreased fetal movements
Mother looks anxious and concerned
DESIRED GOAL/ OUTCOME
To alleviate the anxiousness of the mother
-To clear her doubts about the pregnancy and the well-being of the fetus
PLANNING IMPLEMENTATION RATIONALE
provide and discuss
with her, the ways to improve the
pregnancy outcome with lots of fluids
and nutritious diet
As she is planned of L.S.C.s., importance of the surgery and preparation of the patient.
-patient is kept nill per orally before surgery.
Approach and discuss the
mother’s worry in a calm manner.
-administered in dexamethasone6 mg 6hrly and
told her the importance of this medine
-allow her to ask questions and clear her doubts
provide and discuss with her, the ways to improve the pregnancy outcome with lots of fluids and nutritious diet
-Assure her that the neonate will be kept in the hospital.
As she is planned of L.S.C.s., importance of the surgery and
preparation of the patient.
-patient is kept nill per orally before surgery.
-To alleviate her anxiety
-So that her doubts are cleared
To reduce anxiety related to disease.
-nutritious diet can improve the fetal outcome and increased fluid intake may help raise the amniotic fluid value.
proper care plays a great role in the health of IUGR neonate
Early information about hospitalization helps the
mother to cope after birth of the baby.
to remove any chances of aspiration.
Evaluation: Mother shows less anxiousness about the outcome of labour.
2. Nursing diagnosis : Altered nutrition , less than requirement related to IUGR as witnessed by
low weight of mother
SUBJECTIVE DATA OBJECTIVE DATA
Patient verbalizes weight remaining almost the same Wt= 59 kg
Mother’s weight is almost stationary, with weight being 65 kg approx from 6th month onwards to 8th month
DESIRED GOAL/ OUTCOME to improve the nutrition of the mother, in order to improve the fetal nutritional status
PLANNING IMPLEMENTATION RATIONALE
small frequent meals,
plenty of fluids
-Explained her importance of high protein and high calcium diet for fetal growth e.g. all pulses, milk, soybean, calcium tablets.
To increase the daily intake of diet.
monitored weight -take light food before
surgery
Advised mother to take small
frequent meals
-Advised her to take plenty of fluids
-Explained her importance of high protein and high calcium diet for fetal growth e.g. all pulses, milk, soybean, calcium tablets.
To increase the daily intake of diet.
monitored weight and asked to report weight loss
-adived to keep npo after mid night and to take light food before surgery
Small frequent meals are
tolerate better than large meals
high protein and high calcium diet is needed to improve the growth of the fetus
as weight is not adequate ,daily intake of food should be increased to attain a reasonable weight gain
A decrease in weight should be reported as it
can be due to loss of amniotic fluid and can be
fatal.
Evaluation: Mother has increased her intake of diet.
3. Nursing diagnosis : Deficient fluid intake, less than requirement related to low amount of liquor as evidenced by low abdominal girth=30 inches, and low AFI = 2 and also NPO status of mother before surgery.
SUBJECTIVE DATA OBJECTIVE DATA
Mother verbalizes that her abdomen size is very small
AFI is very low, 2 and low abdominal girth=30 inches I=NPO, O=500ml
DESIRED GOAL/ OUTCOME to increase the fluid intake in order to improve the amniotic fluid volume
PLANNING IMPLEMENTATION RATIONALE
Patient intak output maintained
-Vitals monitored -Catherization prior to
the surgery
- Patient kept npo.
Patient intak output maintained
-Vitals monitored -Catherization done prior to the
surgery
-Iv fludies stated RL/ NS.
Patient kept npo.
intake of fluid helps in production of more liquor
liquor is needed to transport the nutrients to
fetus and excretion of waste
Evaluation: Mother understood the importance of liquor for fetal well being
4. Nursing diagnosis : Knowledge deficit related to care and management of IUGR neonate
SUBJECTIVE DATA OBJECTIVE DATA
Mother verbalizes that she would not be able
to care for a baby of small size
Mother has doubts and less knowledge
regarding care of IUGR neonate
DESIRED GOAL/ OUTCOME
- to improve her knowledge regarding neonatal care.
PLANNING IMPLEMENTATION RATIONALE
explain the importance of exclusive breast feeding for neonatal health and disease
prevention advised to get the baby
immunized as per schedule
explain methods of providing eye care, cord
care and personal hygiene of child
-protect the child from cold as IUGR have inadequate thermoregulation
keep her breast dry and clean to avoid infection
to the child
maintain personal hygiene and handling of
mother was explained the importance of exclusive breast feeding for neonatal health and disease prevention
-she was advised to get the baby immunized as per
schedule she was explained methods of
providing eye care, cord care and personal hygiene of child
-she was advised to protect the child from cold as IUGR have
inadequate thermoregulation
she was advised that the baby
would be kept in nursery for few days until the child is healthy enough for discharge
she was advised to keep her
breast dry and clean to avoid infection to the child
she was advised to maintain
Mother’ milk contains all essential amino acids needed for newborn’s growth and
immunoglobulin’s to prevent neonatal infection
prevent infection.
-timely immunization
would help in preventing known diseases.
-proper care and personal hygiene is necessary to
prevent infection.
-IUGR babies have underdeveloped thermoregulation mechanism; proper care should be taken for such
babies.
-personal hygiene of mother is also essential
baby after proper hand washing to avoid infection
personal hygiene and handling of baby after proper hand washing to avoid infection
Evaluation: Mother’s knowledge increased as she explains the care of baby after birth.
5. Nursing diagnosis : Knowledge deficit related to care and management of IUGR neonate
SUBJECTIVE DATA OBJECTIVE DATA
Mother verbalizes that she would not be able to care for a baby of small size
Mother has doubts and less knowledge regarding care of IUGR neonate
DESIRED GOAL/ OUTCOME to help the mother develop confidence regarding care of the baby - to improve her knowledge regarding neonatal care.
PLANNING IMPLEMENTATION RATIONALE
Explain the importance
of exclusive breast feeding for neonatal
health and disease prevention
advise to get the baby immunized as per
schedule explain methods of
providing eye care, cord care and personal hygiene of child
advise to protect the child from cold as IUGR have inadequate thermoregulation
advise that the baby
would be kept in nursery for few days
until the child is healthy enough for discharge
advise to keep her breast dry and clean to
avoid infection to the
mother was explained the
importance of exclusive breast feeding for neonatal health and
disease prevention -she was advised to get the
baby immunized as per schedule
she was explained methods of providing eye care, cord care
and personal hygiene of child
-she was advised to protect the child from cold as IUGR have inadequate thermoregulation
she was advised that the baby would be kept in nursery for few days until the child is healthy enough for discharge
she was advised to keep her breast dry and clean to avoid
infection to the child
she was advised to maintain personal hygiene and handling of baby after proper hand
washing to avoid infection
Mother’ milk contains all
essential amino acids needed for newborn’s
growth and immunoglobulin’s to
prevent neonatal infection prevent infection.
-timely immunization would help in preventing
known diseases.
-proper care and personal hygiene is necessary to prevent infection.
-IUGR babies have underdeveloped thermoregulation mechanism; proper care should be taken for such babies.
-personal hygiene of mother is also essential
child
Evaluation: Mother’s knowledge increased as she explains the care of baby after birth.
6. Nursing diagnosis : Acute pain related to abdominal incision secondary to surgery.
SUBJECTIVE DATA OBJECTIVE DATA Patient complains of pain in abdomen. Facial expression shows grimace and depression.
DESIRED GOAL/ OUTCOME
Patient will be relieved of pain to some extent.
PLANNING IMPLEMENTATION RATIONALE
Assess the intensity of pain
-Give an analgesic as prescribed
-give a comfortable
position. -diversional therapies
can be helpful. Deep breathing
exercises can be taught.
She is having dull pain over the lower abdomen
comfortable left lateral position has been given.
-mind has been diverted by
asking some questions to the patient.
-deep breathing exercises has been taught to the patient.
Assess the intensity of pain. -To relieve the pain. -it will prevent the pain. -Helps in relaxation
&diversion of mind from
pain. -It helps in relaxation of
muscles.
Evaluation: Pain is reduced to some extent as patient looks comfortable & reports some relief
7. Nursing diagnosis : Fluid volume deficit related to blood loss during cesarean section and
NPO status.
SUBJECTIVE DATA OBJECTIVE DATA
Patient feels thirsty and weak. Patient’s tongue is coated and looks dehydrated. Lips are also dry.
DESIRED GOAL/ OUTCOME
The patient will attain normal fluid volume.
PLANNING IMPLEMENTATION RATIONALE
Monitor I/O chart. -Assess B.P & pulse.
-Administer Iv fluids as
-I/O chart is maintained. -B.P- 110/70 mmHg
Pulase- 86/min
help in analyzing fluid balance & degree of
deficit.
ordered by the physician.
-Place client in recumbent position.
-Allow oral sips as tolerated and ordered by the physician
-IVF RL & DNS are administered as prescribed.
-patient is placed in supine position with legs slightly elevated.
-Hypotension, tachycardia may reflect hypovolemia.
-Helps re establish circulating blood volume & replaces loss.
Optimizes cerebral blood flow.
Evaluation: Normal urine output and patient is taking orally.
8. Nursing diagnosis: Risk for constipation R/T immobility as evidenced by client’s verbalizes of
the physical discomfort.
SUBJECTIVE DATA OBJECTIVE DATA
Patient told that she has not passed stool after surgery & feeling uncomfortable.
Abdomen looks distended and patient looks uncomfortable
DESIRED GOAL/ OUTCOME
Preventing The risk of constipation & establish a normal bowel pattern.
PLANNING IMPLEMENTATION RATIONALE Client is encouraged to take
more fluids in diet.
-Client also encouraged to mobilize.
-Assisting the client while walking.
-Patient was encouraged to take fruits in diet.
Some laxatives may be
provided if prescribed..
Client is encouraged to take more fluids in diet.
-Client also encouraged to mobilize.
-Assisting the client while walking.
-Patient was encouraged to take fruits in diet.
-Some laxatives may be
provided if prescribed.
To increase circulating volume and prevent
shock & to reduce thirst. -Help in softening of
stool. -It will help in retaining
bowel movement.
-laxatives will help in
softening of stool.
Evaluation: Patient is feeling the bowel movement & added the roughage to diet.
She is feeling defecate now.
9. Nursing diagnosis: Self care deficit R/T post operative condition following caesarean section.
SUBJECTIVE DATA OBJECTIVE DATA Patient complains that she is unable to get up to
perform activity and is unable to breastfeed properly.
Patient looks helpless and need
assistance.
PLANNING IMPLEMENTATION RATIONALE
-Note any orders regarding positioning.
-Reposition client every 1-2 hrs & assist client with ambulation & leg exercises
etc.
patient is advised to lie down in supine position & given sponge bath.
-Patient is advised to change positions and
encouraged in leg movements.
-patient is assisted in changing clothes and
perineal care. -Patient is assisted in
breast feeding the child. -Analgesics are
administered as prescribed.
-Family support is encouraged.
Client’s under S.A need to lie flat or without pillow 6-8hrs.
-Prevent surgical complications such as
phlebitis. -Increase feeling of well
being. - Improves self esteem &
client gains confidence in caring for the baby.
-Reduces discomfort. -Promotes sense of well
being.
Evaluation: Patient can perform self care activities.
10. Nursing diagnosis: Knowledge deficit R/T new born care.
SUBJECTIVE DATA OBJECTIVE DATA
Patient asks so many questions regarding how
to care for the baby.
Patient looks anxious.
DESIRED GOAL/ OUTCOME
Patient verbalizes understanding of, & demonstrate the tasks related to new born care.
PLANNING IMPLEMENTATION RATIONALE
-Advise mother to wash
hands everytime before feeding the baby.
-Advise for exclusive breastfeed till 6 months.
-Instruct parents regarding positioning of baby after
feed & advise about burping & its importance.
-Advise mother to always
wash hands before touching the baby.
-Advise for exclusive breastfeed till 6 months
and its importance. -Advise to burp the baby
for 10 min after each feed and lay baby in right lateral
To protect child from
infection.
-Breast milk is the complete food for the
baby. -Positioning new born on
the side reduces risk of aspiration.
DESIRED GOAL/ OUTCOME
To initiate in client’s care of self.
-Demonstrate & supervise infant care activities like feeding and holding, diapering, clothing.
-Instruct parents regarding special care of diapers, recognition of rashes and appropriate treatment.
position after feeding. -Parents were informed to
change diapers immediately after soiling and dry the area & not to use nylon or plastic tight diapers. Inspect the perineal area daily for
redness and induration -Advised to come for
immunization of the baby at 1-1/2 months & its importance.
-Parents are encouraged to verbalize feelings.
-Promotes understanding of new born care; fosters parent’s skill as caregivers.
-Napkin rash is common occurring due to prolonged wet nappies and may cause perianal
dermatitis. -Immunisation is
important and it will prevent infant from many diseases.
-Parents need to recover from the stressful events surrounding child birth.
Evaluation: Mother DemonstrateCorrect feeding technique and burping after feeding.
11. Nursing diagnosis : Risk of Infection related to L.S.C.S., presence of urinary catheter and I.V.
cannula
SUBJECTIVE DATA OBJECTIVE DATA
Patient complains of itching at the episiotomy site, redness at cannula site.
Redness at the episiotomy site; presence of urinary catheter; and cannula site; W.B.C.= 13,000 mg/dl
DESIRED GOAL/ OUTCOME To reduce level of infection so that patient don’t have any complication
PLANNING IMPLEMENTATION RATIONALE
Taught patient about episiotomy care
Maintain hygiene Vitals checked daily
Perineal care giving and catheter care given using sterile
techniques Change pad as needed
Checked the sit of the cannula INJampi500mg T.D.S. given to
the patient for 5 days Removed cannula as advised by
the doctor
Removed urinary catheter Vitals checked daily
To reduce level of infection
Antibiotics reduce infection.
I.V. injections have been stopped.
Evaluation: Patient redness is reduced and itching also reduced
NURSING PROCESS FOR BABY:
1. Nursing diagnosis : Altered nutrition less than body requirements R/T inability of mother to
breast fed.
SUBJECTIVE DATA OBJECTIVE DATA
n/a Weak sucking reflex present and output is not proper.
DESIRED GOAL/ OUTCOME To maintain optimum nutritional status.
PLANNING IMPLEMENTATION RATIONALE Assess weight of the infant daily. -Assess infant for possible regurgitation. -Assess condition of fontanels, skin turgor etc. -Note frequency, amount and description of stool and urine. -Assess mothers feeding practices and knowledge. -Advice the mother for exclusive breast feeding and techniques of breast feeding. Assess the reflexes associated with feeding also.
Baby’s weight is 2.2 kg. -Assess the baby’s sucking and swallowing reflexes while feeding. -Fontanels are open and skin turgor is assessed. -Meconium is passed thrice. -Mother’s knowledge on breast feeding is assessed. -Mother is encouraged for exclusive breast feeding. -Taught the mother signs of good attachment & technique of breast feeding.
-To assess nutrient needs. -To check whether the baby is able to take milk or not. -Depressed fontanels, decreased skin turgor may indicate dehydration. -Evaluates adequacy of oral intake. -Knowledgeable parents are better prepared and respond to feeding needs. -For effective breast feeding.
EVALUATION OF GOAL Nutritional status of baby is maintained. Baby is passing urine & stool properly.
2. Nursing diagnosis : Risk for altered body temperature related to immature thermoregulation.
SUBJECTIVE DATA OBJECTIVE DATA
n/a n/a
DESIRED GOAL/ OUTCOME Baby maintains temperature within normal limits 36.5-37.5oC.
PLANNING IMPLEMENTATION RATIONALE Maintain ambient
temperature at 24oC. -Monitor vital signs. -Keep the baby dry and
wrap in prewarmed blanket.
-Postpone initial bath until body temperature is stable.
-Avoid unnecessary exposure of the infant while changing clothes or diapers.
-Encourage the mother to continue breast feeding.
Normal room temperature is maintained by closing doors and windows.
-Vital signs are monitored and assessed for the signs of hypothermia.
-The baby is properly wrapped in blanket.
-Bath is postponed. -Care was taken not to over
exposed the baby, while changing clothes or diaper.
-Mother is encouraged for exclusive breast feeding upto 6 months of age and explained the importance of skin to skin contact.
-To prevent heat loss of baby. -To assess for any changes in
temperature/Hypothermia. -prevent heat loss through
radiation, evaporation. -Helps to prevent further heat
loss due to evaporation. -To prevent heat loss. -To provide maternal warmth
to baby & eliminate the risk of hypothermia due to
Hypoglycemia.
EVALUATION OF GOAL Infant’s temperature Is stable i.e 37.5oC.
3. Nursing diagnosis : Risk for infection R/T immature defence mechanism.
SUBJECTIVE DATA OBJECTIVE DATA
n/a n/a
DESIRED GOAL/ OUTCOME New-born will be free from the signs of infection.
PLANNING IMPLEMENTATION RATIONALE -Assess the vital signs. -Wash hands properly before handling the infant. -assess the cord and skin area at base of cord daily for redness, odor, discharge. -maintain individual equipment and supplies for each patient. -Ensure that the parents
Vitals are assessed. -Hands are washed before handling baby. -Skin is inspected daily for rashes. Bath is given with mild soap. -Cord is assessed for odor, discharge etc. diaper is folded below the cord stump. -Separate articles are maintained for separate infant. -Parents and visitors are advised to
To note signs of infection like hyperthermia. -Prevent spread of germs. -To prevent spread of infection through umbilicus. -Helps in prevent cross contamination of infants. -Helps in preventing spread of infection to new born.
and visitors to handle the baby with care. -Encourage exclusive breast feeding till 6 months.
handle the baby with care. -Breast feeding is advised.
-Provides immunity to the baby.
EVALUATION OF GOAL No signs of infection are observed.
HEALTH EDUCATION: IN WARD –
Patient is advised to take rest for few days from strenuous activities & also encouraged for early ambulation.
Diet
a. Advised mother to take daily protein like egg, milk and milk products, b. Advised mother to take usual salt but not in excess c. Fluid restriction is not advised
d. Advised mother to take energy and iron rich foods like jiggery spinach, green leafy vegetables, Bengal gram etc.
e. Advised mother to avoid unsaturated fats like ghee and butter.
Advised mother to take sitz bath. She is advised to take her medicines on time and not to skip any dose. She is advised to maintain proper hygiene especially genitals.
Post natal exercises Should not lie crossed leg. Should not carry out heavy lifting of objects till one month.
Initially, she is taught breathing exercise and leg movements lying in bed. Gradually, she is instructed to tone up the abdominal and perineal muscles and to
correct the postural defect. The exercise should be continued for at least 3 months.
The common exercises prescribed are: To tone up the pelvic floor muscles: The patient is asked to contract the pelvic
muscles in a manner to withhold the act of defecation or urination and then to
relax. The process is to be repeated as often as possible each day. To tone up the abdominal muscles: The patient is to lie in dorsal position with the
knees bent and the feet flat on the bed. The abdominal muscles are contracted
and relaxed alternately and the process is to be repeated several times a day. To tone up the back muscles: The patient is to lie on her face with the arms by
her side. The head and the shoulders are slowly moved up and down. The procedure is to be repeated 3–4 times a day and gradually increased each day.
Sexual activity to be resumed (after 6 weeks) when the perineum is comfortable and bleeding has stopped.
DISCHARGE INSTRUCTIONS: Sheis not yet discharged. But health education planned on discharge: Advised to avoid sexual intercourse for atleast 6 weeks.
Family support is encouraged and patient is given psychological support. Advised for exclusive breast feeding till 6 months. Explained about medications how to take & what time.
Explained about immunization of the child till 5 years of age. f. Breast feeding
Advised her to give exclusive breastfeeding for 6 month.
Told her the importance of breast feed for the baby, mother and the society.
Contraception Family planning advice and guidance — o Told mother that the method of contraception will depend upon breastfeeding status,
state of health and number of children.
o Natural methods cannot be used until menstrual cycles are regular. Exclusive breastfeeding provides 98% contraceptive protection for 6 months. Barrier methods may be used. Steroidal contraception — combined preparations are suitable for no
lactating women and should be started 3 weeks after. In lactating women it is avoided due to its suppressive effects. Progestin only pill may be a better choice for them. IUDs are also a satisfactory method irrespective of breastfeeding status.
Sterilization (puerperal) is suitable for those who have completed their families. Planning for future pregnancy: If patient plan’s for second pregnancy she should gap of 2-3 yrs. and should have regular antenatal the checkups to reduce high risk pregnancy.
PROGRESS NOTES: Patient improved very well from her condition. She is able to walk with assistance now
and also able to do her self-care activities also. She progressed well from her disease state. Intake output maintained and vitals are stables. Pain reduced. No signs of infection. She understood how to breast feed and importance of breast feed. No further
complaints. PROBLEMFACED BY THE PATIENT AND STUDENT
The mother verbalized that there was no one to comfort her in labor room during the labor pains. She was only given the gown once and no food was given to her. She also said that 2-3 patients are together given one bed.
There is no privacy for antenatal palpation in the ward. There is overcrowding of patient attendants. Sometimes there is lack of supplies e.g. disposable bed sheet for providing care for the client.
PERSONAL OPINION AND ACHIEVEMENTS. The case study I took was MOTHER WITH OLIGOHYDRAMNIOS AND IUGR. The care for the mother diagnosed with OLIGOHYDRAMNIOS AND IUGR is similar in regard to the
treatment and there is no complication. Patient was a registered case in antenatal clinic. Her diagnosis was done at the earliest and treatment given according to theory. She stood all the treatment and gave birth to a 1.8 KG boy baby at 1:26 pm on 3/8/2016 by
emergency L.S.C.S under spinal anesthesia. She along with her baby received adequate medical and nursing assistance and was recovering well. She was not yet discharged till my posting.
RECOMMENDATIONS Each individual experiences of pregnant mother are unique and care is to be
provided by keeping that in mind
The treatment for each different abnormal conditions are specific, thus care should be prioritized as per the need
Not only physical care but emphasis should also be given to the emotional and psychological aspect of care in mother
The support and involvement of family members are required and should be
encouraged. SUMMARY AND CONCLUSION:
I got the patient, Mrs Dolly W/O Sunny, aged 20yr/f on 2/8/2016 in ward-4. She came in the opd with diagnosis Primi with 38+1 wks with oligohydramnios & IUGR for she admitted to ward-4. Emergency LSCS was done on 3/8/2016 and delivered a boy baby
with 1.8 kg birth weight at 1:26 pm. I care her for 5 days. It was a very nice experience for me. I was able to plan nursing activities and was able to carry out and evaluate them effectively. The condition of my patient improved after my nursing care. She and her baby are healthy without developing any complications.
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